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NC Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
 
 

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The Department of Health and Human Services (DHHS) has approved a definition and description of a new category of provider agency, Critical Access Behavioral Health Agency (CABHA). The CABHA is designed to ensure that critical services are delivered by a clinically competent organization with appropriate medical oversight and the ability to deliver a continuum of services. The CABHA will move the public system over time to a more coherent service delivery model that reduces clinical fragmentation at the local level and begins to prepare the provider community for the changes that will be required in a waiver environment.

Goals of Critical Access Behavioral Health Agencies


The Department's goals in developing the Critical Access Behavioral Health Agency designation are to:

  1. Ensure that critical services are delivered by a clinically competent organization with appropriate medical oversight and the ability to deliver a robust array of services.
  2. Move the public system over time to a more coherent service delivery model that reduces clinical fragmentation at the local level and begins to prepare the provider community for the changes that will be required in a waiver environment.
  3. Ensure that consumer care is based upon a comprehensive clinical assessment and an appropriate array of services for the population to be served. For example, a provider who will serve only children with mental health issues might offer outpatient therapy, case management, intensive in-home and day treatment. The array will vary depending upon the age and needs of the consumers to be served by the agency.


Certification Process


Critical Access Behavioral Health Agency status will be certified once for the entire state through a review by a certification team comprised of licensed staff from Local Management Entities (LMEs) in the region in which the Critical Access Behavioral Health Provider is located and State staff: the Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS), and the Division of Medical Assistance (DMA). This certification process will include:

  • Submission of an attestation letter with supporting documentation from a provider that the provider meets the certification requirements to be a CABHA.
  • A desk review, conducted by DMH/DD/SAS, with collaboration with the Divisions of Medical Assistance and Health Services Regulation, including determination of "good standing" status in the Department.
  • A verification process conducted by DMH/DD/SAS and the LME where the provider is requesting CABHA certification to verify components in the Letter of Attestation and confirm compliance with CABHA requirements.
  • Interviews of provider staff by the certification team, including staff representation from DMH/DD/SAS; DMA and LMEs.

A CABHA must meet the terms of the DMA Provider Enrollment Agreement and DHHS policy. CABHAs are required to meet site specific LME endorsement standards for all enhanced services, in each LME area where the service is to be delivered. This requirement will apply also to mental health case management services and peer support, once approved by CMS. The provider will still be required to enter into standardized Memoranda of Agreements (MOAs) with LMEs in the catchment areas in which they have a service specific site endorsement and a standardized contract with the LMEs for State-funded services. Continued certification as a Critical Access Behavioral Health Agency will be based upon the agency's meeting or exceeding the required performance standards established by DHHS. The basic elements associated with the certification of CABHAs include the following:


Certification Requirements


Active National Accreditation for at Least Three Years
Critical Access Behavioral Health Agencies will have a three year (or longer) accreditation from an accrediting body recognized by the Secretary of the Department of Health and Human Services (e.g., the Council on Accreditation [COA], the Commission on Accreditation and Rehabilitation Facilities [CARF], the Council on Quality and Leadership [CQL], and The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations [TJC]).

Staffing Requirements
Medical Director: A Critical Access Behavioral Health Agency shall have a Medical Director who must be a board certified/eligible psychiatrist (MD or DO) licensed in NC; or board certified/eligible physician licensed in NC who has ASAM/ABAM certification. See Implementation Update #68 & #70 for information on exceptions to this standard.

  • Either 100% or 50% FTE (depending on number of consumers served by the CABHA) to be onsite. Providers serving more than 750 consumers must have a 100% FTE Medical Director. Providers serving less than 750 consumers may operate with a 50% FTE medical Director. CABHAs must ensure that consumers served in any location have access to medication administration services. CABHAs serving more than 750 consumers at any site other than the CABHA certification site must designate a Lead Physician for that site who functions under supervision and direction of the CABHA Medical Director. Note: CABHAs required to have a 100% FTE Medical Director may fill this requirement with no more than two different physicians. CABHAs required to have a 50% FTE Medical Director must allocate this function to no more than one physician. The loss of this position for more than 90 days will require a review of the agency's status as a Critical Access Behavioral Health Agency.
    • 100% FTE = 40 hrs per week/ 50% FTE = 20 hrs per week
  • For those agencies required to have a full time Medical Director and who fill this position with a psychiatrist or ASAM/ABAM certified physician—the Medical Director and Clinical Director functions may be performed by the same individual but may not provide any direct service.
  • The Medical Director is responsible for:
    • Overall supervision of all medical/clinical aspects of the services delivered.
    • Identifying appropriate evidence-based or emerging best practices therapies to be employed by staff in delivering services.
    • Oversight of all quality management initiatives.
    • Ensuring the coordination between the MH/SA services being delivered with primary physical healthcare providers.
    • Consulting with primary healthcare providers on the clinical aspects of the consumers being
      served and the implications for those consumers physical healthcare needs.
    • Coordinating with medical staff of other providers, e.g. state and community inpatient
      facilities.
    • Supervision of all other medical staff within the provider agency.
  • The Medical Director may provide direct services up to 60% of budgeted time subject to appropriate performance in meeting the required clinical management and oversight functions.
    • The Medical Director must be enrolled and in good standing with NC Medicaid.

Clinical Director (100% FTE): A Critical Access Behavioral Health Agency shall have one FTE licensed clinical director, shared by no more than two individuals, on-site, with education and experience sufficient to provide clinical direction to the staff employed by the provider agency. Individuals with provisional licenses may not serve as the agency Clinical Director. The Clinical Director may not provide direct services.

  • The Clinical Director must meet one of the following licensed discipline categories:
    • Physician or Psychiatrist
    • Licensed Clinical Social Worker
    • Licensed Psychologist (Doctorate Level)
    • Licensed Psychological Associate
    • Licensed Professional Counselor
    • Licensed Marriage and Family Therapist
    • Mastered Degree Nurse – advanced practice only (NP, PNPs)
    • Licensed Clinical Addiction Specialist
    • Certified Clinical Supervisor
  • The clinical director is responsible for:
    • Supervision of all non-medical direct care staff in the provider agency
    • Design of the treatment protocols employed within the agency
    • Ensuring appropriate assessments for all consumers served
    • Implementation of best practice and emerging practice protocols
    • Reviews of service quality
    • Design of all staff training

Quality Management/Staff Training Director (100% FTE): A Critical Access Behavioral Health Agency shall have one FTE Quality Improvement/Training Director shared by no more than two individuals. The CABHA must demonstrate that the individuals in this position have evidence of quality improvement and training activities. This position requires a Bachelors Degree and three years experience or a Masters Degree and one year of experience utilizing data to support the development of quality services.

  • The QI/Training Director is responsible for:
    • Development of a quality improvement/quality assurance plan
    • Ensure compliance with all documentation, staff qualification and all other state and federal requirements for the services being delivered.
    • Oversight of staff credentialing process
    • Staff support for the quality improvement committee
    • Developing and reporting consumer outcomes and comparing the agency's performance to outcomes achieved by other, similar providers
    • Development and implementation of a protocol for continuous staff training designed to achieve all requirements of the services being delivered.

Note: The clinical oversight and management functions represented by these positions must be actively in place at least two months prior to the provider receiving an onsite review for CABHA certification.
Service Array
Each Critical Access Behavioral Health Agency is required to offer the following Core Services:

  • Comprehensive Clinical Assessment
  • Medication management
  • Outpatient therapy

and
to be endorsed for at least two additional services (from the list below) in the same region where it provides the three services indicated above (and thus, creates a continuum of care for the age/disability of the consumers to be served): Please see Implementation Update #66 and #70 for more information on requirements for service continuums.

  • Intensive In-Home (IIH)
  • Community Support Team (CST)
  • Substance Abuse Intensive Outpatient Program (SAIOP)
  • Substance Abuse Comprehensive Outpatient Treatment (SACOT)
  • Child Residential Level II, III, and IV
  • Day Treatment
  • Psychosocial Rehabilitation (PSR)
  • Assertive Community Treatment Team (ACTT)
  • Multi-Systemic Therapy (MST)
  • Partial Hospitalization (PH)
  • Substance Abuse Medically Monitored Community Residential Treatment
  • Substance Abuse Non-Medical Community Residential Treatment
  • Outpatient Opioid Treatment

In addition to the above services the CABHA will be responsible for providing Case Management Services (both Medicaid/ State funded) for mental health and substance abuse consumers when this service is approved by CMS for implementation. Case Management will be paid on a monthly case rate as defined in the service definition, provider qualifications, and required consumer outcomes. Note: Targeted Case Management for consumers with developmental disabilities will continue to be delivered outside the CABHA requirements.

Once certified as a CABHA, Peer Support services may be delivered anywhere in North Carolina. However, CABHAs are required to meet site specific LME endorsement standards for Case Management and Peer Support (the implementation timeframe for these two services will depend upon CMS approval), as well as for all enhanced services that the CABHA plans to deliver. CABHAs need not meet the certification criteria in every location in which they deliver Case Management and Peer Support services. If a CABHA chooses to offer peer support in a location in which they do meet the certification requirements, they must also deliver case management services in that location. Effective January 1, 2010, Case Management services not included within a "clinical home" service definition will only be delivered through CABHAs. Once the service definition for Peer Support is approved by the CMS, the only agencies allowed to provide that service will be CABHAs.

In order to have a determination made prior to July 1, 2010, providers of Intensive In-Home, Community Support Team, and Day Treatment services will have until April 1, 2010 (per Implementation Update #70) to submit a letter of attestation for CABHA certification. Current providers of Intensive In-Home, Day Treatment and Community Support Team that do not achieve certification as a Critical Access Behavioral Health Agency by July 1, 2010 will have their endorsement to provide that service involuntarily withdrawn and the enrollment for those services will be terminated from the Medicaid program. In other words, effective July 1, 2010, only providers certified as CABHAs may continue to deliver or be enrolled to deliver Community Support Team, Intensive In-Home, or Day Treatment.
While CABHAs may deliver a broad array of services, please note that a number of enhanced services may still be delivered by providers who are not certified as CABHAs.

Funding Sources
A CABHA shall serve consumers who are eligible for Medicaid as well as indigent consumers supported by State funds. In serving consumers funded with state funds, referrals must be for services provided by the provider, the regulations governing the use of funds must be materially similar to Medicaid regulations, and the rates paid for services must be no less than the Medicaid rates. CABHAs must seek to become eligible to be paid for services by all third party payors that reimburse for services that the agency delivers (e.g. private insurance, Medicare, TriCare, etc.).

Performance Bond
When deemed necessary "to be in the best interests of the Department," a Critical Access Behavioral Health Agency purchasing the Performance Bond must meet the requirements set forth within such bond.

Collaboration with Physical Health
Critical Access Behavioral Health Agencies will be expected to maintain close collaboration with primary care physicians, public health departments, Federally Qualified Health Clinics, and Community Care of NC, in order to ensure that the consumers being served are treated in a holistic manner that addresses both their behavioral health and physical health care needs. (3/15/10)

 

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